406548_Well Construction - GW1_20120711

N
ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4108-B
1. WELL CONTRACTOR:
William Kicker
Well Contractor (Individual) Name
Mad Dawo, Inc.
Well Contractor Company Name
1006 Camp Creek Rd
Street Address
Iron Station
City or Town
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 28080
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) AS-8 .
3. WELL USE (Check One Box) Monitoring ii Municipal/Public 0
Industrial/Commercial D Agricultural ❑ Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 6-15-12
4. WELL LOCATION:
5200 Wrightsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington
TOPOGRAPHIC / LAND SETTING:
Slope ❑Valley elat ❑ Ridge
LATITUDE 34 012 ' 715.0000
COUNTY New Hanove
(check appropriate box)
❑ Other
" DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 0 51 • 964.0000 „ DMS OR 7X.XXXXXXXXX DD
Latitude/longitude'source: 3PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Former Scof chman #182
Facility Name Facility ID# (if applicable)
5200 Wrightsville Ave
Street Address
Wilmington NC 28403
City or Town State Zip Code
Bryan Lievre
Contact Name
P.O. Box 12055
Mailing Address
Wilmington NC 28405
City or Town State Zip Code
( 910,6 932-3050
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 50'
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 8'
(Use "+" if Above Top of Casing)
YES O NO Cyir
FT.
d. TOP OF CASING IS 0 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A. METHOD OF TEST
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 45' Ft. 2" Sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
: Top 0 Bottom 40'
Top 40' Bottom 43'
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 45' Bottom 50' Ft. 2" in. .010 in. PVC
Top Bottom Ft. in. in.
Top, Bottom Ft in. in.
Material
Ft. Portland
Method
Trimmie
Ft. Bentonite Pour
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top 43' Bottom 50' Ft. #2 Silica
Top Bottom Ft.
:Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
• • 0 /50'
•
/.
•
•
/
•
/
12. REMARKS:
Formation Description
Silty Sand
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION ST : N i DS, D THAT A COPY OF THIS
: RECORD HAS BEEN PR0\ DED TO TH -i / OWN
•
1/10&" ‘0-(q-ig
•
SIGNATURE OF ERTIFI LL NTRACTOR DATE
r/'et-Akt, /it 4-,e./
PRINTED NAME OF RS N CONSTRUC ING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09